Friday, September 13, 2019

This addresses concerns that folks who had become eligible for an SEP but unable to finalize a new plan because of storm-related issues will get another bite at the apple:

"Consumers who qualified for an enrollment period, such as an SEP, but were unable to complete a Marketplace application, plan selection, or enrollment process due to Hurricane Dorian, may have access to an Exceptional Circumstances SEP."

They get an extra 2 months (well, 60 days) to log in and enroll, and "request a retroactive start date based on when he or she would have picked a plan if not for Hurricane Dorian."

Thursday, September 12, 2019

Back on August 31, we purchased a new oven from our local Lowe's store (wanted to support the local folks instead of ordering online). That proved to be a mistake.

We were promised delivery by today (September 12), and that was the last we heard from them.

No follow-up, no notification, nothing.

So I called the store this morning, and was informed that the delivery had been pushed out to the 22nd.

Again, no one bothered to communicate this to me. I only learned of it because I initiated the call. I told the manager that this was not acceptable, and that I expected delivery today. He insisted several times that he couldn't promise that. No effort was made to accommodate or offer alternatives.

So I called corporate, and was informed that the oven had been delivered to the local store, but because Lowe's store managers are incompetent, I had to learn from the nice lady on the phone that their rule is that they can't send items out for delivery on the same day, and that tomorrow's deliveries are already booked.

To her credit, she reached out to the "delivery coordinator" and promised me that she'd have him contact me directly to makearrangements. I eventually heard back from the coordinator, who was able to move the delivery up to this coming Sunday (Yay!).

So, all's well that ends well?

Not hardly: I should not have had to call them to find out what was happening, and the fact that each person I spoke withhad a different story, is unacceptably poor customer "service."

We havehad been long-time, loyal customers, but no longer.

It's worth noting that other stores, like Home Depot and Best Buy, will generally match Lowe's prices.

Unfortunately, these appear to have been largely ineffectual, and she's now at a very dark place indeed:

"The only treatment that is anticipated to help her is expensive, costing $6000-7,000 per infusion, and the doctor has prescribed 6 infusions to enable her body to reconstitute itself and get her on the road to recovery."

To that end, her family has set up a GoFundMe campaign [full disclosure: I have donated to it] hoping to raise enough money to cover most (if not all) of the expected costs.

Okay, a worthy cause, but why isn't her insurance company covering it (or at least most) of it)?

Well, that's because the carrier, Aetna, "has refused to pay for the treatments, calling the drug "experimental" and providing no recourse for her worsening condition."

Seems familiar, no?

[ed: for the purposes of this post, we'll table discussion of an insurer's putative responsibility to offer alternative treatment suggestions]

As noted in the GFM, there have been appeals and advocates, apparently to no avail.

As a parent and husband myself, I can certainly sympathize with the family's plight, but I have some questions.

So I've reached out to both Sarah's family and her insurance company, and would like to share what I've learned:

Her father, who was very nice and forthcoming, had no direct knowledge of the plan's details. He in turn put me in touch with his son-in-law (whose employer's coverage is the insurance at issue). Unfortunately, he has yet to respond (I'll update the post if/when he does).

In the meantime, I also reached out to Aetna:

"Good morning!

We're working on a post about [the GoFundMe], and would like to have Aetna's side, as well. We understand that you can't comment about this case specifically, but would be interested in speaking/emailing with a claims person who can address the dynamic between experimental vs medically necessary treatments.

Looking forward to hearing from you."

About which co-blogger Bob gently prodded me:

"Still tilting at windmills?

Carriers RARELY set their own standards for medical necessity, experimental, provisional. Much easier to follow CMS guidelines as in "it's not my fault, this is how Medicare handles it."

Doubt you will get very far with this, even without factoring PHI complexities."

I knew that he was right, but "in for a penny...."

In the event, I did, in fact, hear back from them:

"Hi Henry:

My name is Ethan Slavin and I work in the Communications department at Aetna. While we can’t comment on this specific situation (as you noted), we can provide you with our general overview on how we make coverage decisions.

You are welcome to use information from this page for your post, as you see fit.

Please let me know if you have any questions."

Which was not unexpected, and actually helpful.

I would still like to know whether or not the plan in question is self-funded (because that could make a difference), but the reality is that Bob's correct, and while sad, this is pretty standard, and not subject to online petitions and the like.

Again, I'd ask why the venom is being directed at Aetna and not the folks with the high-priced meds, or the providers who would administer them.

[Full disclosure: I am not active in the Medicare Supplement/Advantage market]

Recently received this in email:

"New for 2020: Lasso Medicare Savings Account Plan"

Medicare MSA's appear to be the post-65 version of what we typically see as Health Savings Accounts (HSAs) in the pre-65 market, with some interesting twists:

• $0 Premium• MSAs are one type of Medicare Advantage (MA) plan that the Centers for Medicare and Medicaid Services (CMS) partners with private insurance companies to offer. MSAs combine a high deductible health plan covering Medicare A/B expenses with an IRS-approved trust/ custodial savings account. • No admin/monthly fees for MSA account while beneficiary is on plan• See any provider or hospital that excepts [sic] Medicare!• Individual must enroll in a stand-alone [Part D Rx Plan]. • HSA account funds can transferred into new MSA accounts. • Plans are available in every county in the states where they are available [ed: go figure].

I checked with co-blogger Bob V (who's very active in the Medicare market) and he confirmed that the idea is legit.

This particular iteration is intriguing, since the vendor, not the insured, is making the actual deposit. Once that's made into the insured's account, it's immediately vested, and can be used for medical-related items (like doctors' visits and rx co-pays). Since it's 100% the insured's money, there's definitely some 'skin in the game,' and we can see that in action:

"[A]s of September 1, 2019, 81% of all Lasso Healthcare MSA plan members had spent less than $1,000 in their current benefit period!"

Hunh.

[ed: I reached out to see if the insured/beneficiary could also contribute to the account, and will update this post if/when they reply]

Currently, the Lasso plan is available in over 25 states (almost half of them!).

"The owners ... have blamed their insurers for a lawsuit that they filed to limit their payouts to victims' families, calling it an "unfortunate side of these tragedies."

Oh sure, blame the insurer.

On the other hand, it's the insurer's duty to its policyholders and owners (stockholders) to limit those damages, and that's why they keep lawyers on hand for just this kind of situation. It does seem rather crass, but the insurer is also bound to do all it can to mitigate the damages. And the timing, while unfortunate, may have little to do with lack of compassion, and much to do with timely filing.

Our hearts, of course, go out to those families, but this seems to be strictly business.

To be sure, there are still quite a few other permanent-type plans out there with the same issue.

And what issue is that, Henry?

Well, when these plans "mature" while the insured is still alive, that person is likely to be hit with a pretty hefty tax bill; that is, the policy is paid out as a lump sum to the insured, and any excess over the total premiums paid are taxable. That could be a sizeable sum indeed, and is a double whammy (since that policy is now canceled).

Until now, there really wasn't much one could do about in-force plans (hence the clarion call for a class action lawsuit).

But in a Long Term Care insurance (LTCi) product training session last week, I learned about another product that might be a solution to the tax issue:

OneAmerica Life offers an annuity product that's available to folks up to 99 years old, and doesn't require forced annuitization (or Required Minimum Distributions). While marketed as a potential LTCi alternative, it struck me as solving at least part of that "maturation" problem, since there's no immediate funds to pay out and thus be taxed. Called "Legacy Care®," it lets one roll-over the cash value of an existing life insurance policy and continue to defer taking the tax "hit" (although it's going to fall to one's heirs eventually).

Not perfect, of course, but at least a little light at the end of the tunnel.

An actuary on the staff at the National Association of Insurance Commissioners is wondering whether, and how, the existence of nonbinary people might affect the world of life insurance.@naichttps://t.co/w66AR7pAhd

It's silly because (for starters) trans/other Americans comprise barely a rounding error of the general population. Actuaries, by definition, work with very large groups, not infinitesimally-small ones, which would yield an essentially meaningless sample.But wait, it gets "better:"Actuaries estimate "probability of risk," that is, the likely number of expected deaths from a (again, large) population; it's merely a pricing tool.The only opinion that matters here is the underwriter's, because his job is assessing the specific risk, and then deciding whether or not it's acceptable, and at what premium (rating factor).In the event, neither of these folks would ever even see such an application in the firstplace, for a very simple reason: all life applications require one to provide name, socialsecurity number, date of birth, and sex (among other things). Applications missing this information will be returned to the agent for completion.There's also the small problem of the "misstatement of age or sex" clause, which would come into play at claim time.But even more important, from that underwriter's point-of-view, is this:"As I discussed with a life field rep friend a while back, the life company is likely to decline the case altogether because of the increased suicide risk."By the way, these issues would also come into play with auto, disability income, long term care and other types of insurance, as well. Which means a lot of wasted time for a trifle.Talk about much ado ....

Why would lawmakers be interested in making these prices transparent,
since the only time you would use an Air Ambulance is in an Emergency?

Because customers have received “surprise air ambulance bills …from insurers that have denied
claims for emergency transport, saying the rides weren't preauthorized or weren't necessary.”

I have seen my share of unwarranted
denials, but this takes the cake. In an emergency there is no time to get a
Preauthorization. A Preauthorization is usually required for any type of
surgery, lab, test, or medication that will require a significant reimbursement
by an insurer. Preauthorization’s can take anywhere from 48 hours to weeks to
obtain. Obviously if you are bleeding on the side of the road and will die
without immediate medical coverage you cannot wait for a Preauthorization.

As to the necessity, once again, it
is self-evident.

It is this idiocracy of thinking by
insurance companies that hinder medical decision making. While this is an
extreme of insurance meddling in medical decision making, this interference
occurs hundreds of times a day in every medical facility across the nation.

Josh Wilkerson had recently come off of his stepfather's health insurance (he had reached that magical age of 26) and had elected not to buy his own. As usual, the reporter doesn't bother to ask why Mr Wilkerson chose to "go bare;" at his age a catastrophic ACA plan would have cost about $300 a month (assuming he didn't use tobacco). At least one plan appears to cover insulin.

Be that as it may, the high cost of "regular" versions of the med have become quite expensive, which is a problem for any number of reasons, not the least of which is this:

How we got here is outside the scope of this post, but there appears to be more than enough blame to spread around.

So what is the point of this post, you ask?

Well, it's actually quite simple (for certain values of "simple"):

Regardless of how we got here, it's a big problem, so how do we fix it?

Of course, many folks would have the government wave its magic wand and legislate that it be covered at little or no expense (for those who are insured) or provided at little or no cost (to those who are not).

Which seems reasonable on its face, until one considers this:

3/3 I'm expecting their next proclamation to involve insulin for all diabetics, as Schedule "A" wellness. This will really beat up your health insurance, the math is staggering.30.1m people x $1,200/month average = $433 Billion in new health insurance premiums to be paid.

The new short-term care insurance product will help purchasers pay for short-term use of home health care, adult daycare, hospice care, assisted living facility care and nursing home care, according to AARP and American Enterprise.@AARPhttps://t.co/Qn2gWdEvCA

Tuesday, August 27, 2019

The individual market is 37% larger than it was in 2013. That’s because the federal govt is covering much of people’s premiums, not because we added “protections” which drive up base premium rates. https://t.co/wd4UdvwbEphttps://t.co/llUlFKLwqJ

Monday, August 26, 2019

Well yes. A study of cataract surgery in the UK showed that delaying surgery at least a year resulted in many patients dying, becoming too sick or forgetting about it so the numbers of actual procedures were reduced. It is a form of self-rationing then allows access to others.

Friday, August 23, 2019

Well, technically "Grandfathered:" the plan in question dates from 2010, when we wrote it for a younger couple and their 3 (now 4) children. This was one of my favorite plan designs: Anthem's Lumenos HSA product, a legit cat (catastrophic) plan with a $10,000 family deductible, then 100% after. Fit their needs well, and was a great value.

Fast forward 9 years, and (sadly) they're divorcing. Which wouldn't be the end of the world insurance-wise but for a couple complications:

First, now ex-hubby has opted for a Sharing Ministry for himself and the kids, and has failed to pay the August premium. Oh, did I mention that I just learned about all this yesterday?

/sigh

Anyway, Jane reached out to me to fill me in and to ask about her options, . since she would prefer an actual insurance plan. It doesn't look like she'd be eligible for a Special Open Enrollment opportunity (since her plan isn't ACA-compliant), but perhaps she could keep the Lumenos/Anthem plan?

So I reached out to Anthem and learned that she could, in fact, keep the plan (there are some hoops through which she'll need to jump, including getting ex-hubby's signature on the change request).

So what's the dilemma, Henry?

Well, since the August premium is apparently unpaid, the plan is in the 30 day grace period, and that clock is ticking. Once that's over, so's the plan, and the opportunity to keep it. In the meantime, she's waiting to learn whether or not she's been approved for the new job for which she's applied, but won't know that until the 30th.

Which is also the deadline for the change request.

Yikes.

I've suggested that she submit the request anyway, since it doesn't involve sending in any actual money, and she can always change her mind if/when she gets that new gig.

The ongoing saga of Mount
Carmel Health System in my home state of Ohio should be a wakeup
call for all Medical Organizations. Specifically, that Doctors are fallible.

But to the root of the problem, how did this happen. It happened
because Medical Organizations are created by Doctors who have a "negativity
bias."

How does the negativity bias affect patient care? Catherine
Hambley, PhD discusses this in an article, “What you can do about the
negativity bias in Medicine.

“The negativity bias is alive and
well in medicine. It starts in
medical school where students are frequently exposed to teaching methods that
create feelings of shame, ineptitude and incompetency. Early on in their
careers, physicians learn both the importance of preventing and avoiding errors
as well as the need for perfection.”

This trait is then carried over
into their working lives and into the Medical Practices and Organizations in
which they create and work. Staff is expected to maintain this super human
level of perfection, which causes tremendous stress and burn out. As Dr. Hambley
states:

“…we
know that mistakes are inevitable. We also know that if we talk about them, we
are more likely to prevent their recurrence. The problem is that healthcare workers often avoid acknowledging that an error
has occurred. This is typically due to a
culture where mistakes are accompanied by some form of punishment, and people
often feel humiliated and blamed. Hospital settings can also perpetuate a
culture where the negativity bias is enhanced with physician peer review
committees and incident reporting systems.”

I have seen this negativity time and again in the Medical
Profession. Staff are intimidated not to complain about the “Bad Doctor”
because they have seen their peers who do complain punished. In job interviews
I am always asked about dealing with the “Bad Doctor”. I always know when that
question is coming because the interviewer becomes quiet, usually sighs or
breaths in audibly, and then tentatively begins the question. The question is
asked because there is a “Bad Doctor” in the organization that has been
ignored, supported, and accommodated when in reality he/she should have been
acknowledged, discouraged, and censored.

What happens instead is that good, ethical employees become
jaundiced to management, which effects their job performance and ultimately
leads to less than adequate care. The case of Mount Carmel is the extreme, but
it will happen again as long as the Infallibility Mindset is a part of Medical
Management.

One of my life insurance clients called the other day to see if I could help her with her sons' policies. Seems she had bought each of them a Universal Life policy some years ago (before we'd met) and she wanted to professional advice. I was of course happy to oblige, and asked her a few questions:

The plans were about 20 or so years old, and written by her Auto Owners Insurance agent. He has since retired, and the agency to which the plans were re-assigned hasn't been particularly helpful. She did have the annual statements handy, and we were able to determine that the plans were doing well so far (a welcome relief: they often get "upside down" this far in). But it seemed to me that it wouldn't hurt to increase the premium a bit as a hedge against future slumps. To that end, I suggested that she contact AO directly to see about obtaining in-force illustrations (aka "what-ifs") for each plan.

Here's why: due to various tax laws over the years, there is a cap on how much one can put into a given UL each year (yeah. I think that's dumb, too, but there you go). So we needed to determine if we could bump the premiums, and if so, to what effect. Quite routine, really.

What happened next is decidedly not routine: when she called the Home Office, she was told that only her agent could order these illustrations. Putting aside the obvious question of what if she had no agent, why is it the carrier's business if she wanted them? As the owner of the policies, she has every right to this information (as well as changing beneficiaries, premiums, etc).

And even if she wasn't the owner, she should have been told that her sons would need to make the request themselves (not her on their behalf). There's just no excuse for how poorly this was handled. One wonders how she would have been treated if it was a claim.

Shame on Auto Owners Insurance.

[ed: we generally like to give carriers a heads' up on, and opportunity to correct, these types of issues, but AO doesn't seem to have a media relations contact email available]

"The SEP will run from July 1, 2019 until September 4, 2019. Eligible consumers should have received a notice ... advising them of the availability of this SEP. CMS will evaluate an individual’s eligibility for the SEP using Simple Health Plan enrollment information."

Oh goody.

Here's why I'm ambivalent about this:

There were plenty of folks who played by the rules of the game and bought legit policies who were then left high and dry. Why are the SHP folks given preferential treatment? Perhaps it's because the FTC is suing the carrier, but what does that have to do with CMS?

Friday, August 16, 2019

In medical terms, a “Never Event” is an event that should never
happen, like a wrong site surgery or killing a patient. An article in today’s
medical reading clearly demonstrates a real time Billing Never Event, that unfortunately
occurs much too often in medical clinics.According to WCPO
in Cincinnati (OH), a mom had to be pay a bill before her daughter would be seen
at a walk in clinic.The story begins:

“Jessica Vance wanted to avoid a
$1,000-plus emergency room bill, when her 8-year old daughter recently
developed a cough and fever.

So she took her to a walk-in clinic inside a local grocery store.”

Problem number one: Why doesn’t this family have a
Family Practice Doctor? One of the cited reasons for America’s high health
costs is the use of Emergency Rooms for non-emergent conditions, such as this
case. If mom had established herself with a Family Practice Doctor, she would
have either been seen that day, or at the very least prescribed a medication
with a follow up visit, for the cost of a co-payment.

But I digress, let’s continue the saga:

“But when Vance spoke to the woman at the desk, she
received some stunning news. The employee said Vance had a $690 unpaid balance,
from an insurance payment that had not yet processed.

So the employee said Vance's daughter could not see the
nurse, and suggested they go to an emergency room if they needed immediate
help.

"I said 'what do you meant you won't see her?' Vance said.
"They told me I have a balance due. I asked them 'can't you call
insurance?' They said no, they could not."

So she reluctantly she put the past due amount on her credit card,
rather than drive across town to an emergency room, and a much larger bill.

"I ended up having to pay $690 that day for her to be
seen," Vance said.”

This is where the clinic made its mistake, and it is a
huge mistake. Yes, clinics, doctors, etc. can refuse care for non-emergent
cases when the patient has a balance due. However, in this case there was not a balance
due. Let’s look at the sentence again:

“Vance had a $690
unpaid balance, from an insurance
payment that had not yet processed”

If the claim had not yet been processed by the
insurance company, there is no balance for the patient to pay. When a medical
entity agrees to be an in-network provider, which means that the entity agrees
in a contract to submit claims to an insurance company for payment and not
collect from the patient at time of service, then the patient cannot be billed
for any monies owed until that claim is processed. The clinic violated the
contract with the Insurance Company and as such the Insurance Company has
grounds to nullify that contract, resulting in the clinic becoming a
non-participating provider.

Now to make matters worse, the article reports that
the Insurance Company paid the balance due in full but mom has not yet been reimbursed
the funds. This is the ultimate insult.

While a clinic has a right to deny treatment based on an
unpaid balance, the patient would have to be notified in writing that this was
the policy and the patient would have to sign a document acknowledging that
policy. (When I manage an office, my Policy and Procedure Contract with Patients
is about 11 pages long.) Without that signed documentation, the clinic cannot
deny treatment based on monies due, as this is outside the contract that the
Patient and the Insurance Company have with the provider.

ACA-compliant plans have certain features and rules, one of which is that chronic care can't be considered a first-dollar expense. That is, unlike, say, a routine physical, chronic expenses must first be applied to one's deductible and co-insurance (if any). Turns out that a lot of folks who actually suffer from these issues would like relief from this requirement.

This becomes a problem for HSA policy holders, because doing that would render their plans non-compliant (and result in all kinds of nasty consequences). And so, the generous folks at the IRS have issued a ruling that reverses (or negates) that, and specifically allows such plans to cover some chronic expenses "first dollar."